In this update:
- Administration Updates
- Senate Confirms Dr. Monica Bertagnolli for NIH
- Federal Agencies
- CMS Proposes MA Rule on Behavioral Health and Marketing
- CMMI to Hold Office Hours for Making Care Primary on November 21st
- CMMI to Hold Listening Session to Hear Beneficiary Feedback on November 15th
- CMS Launches “Birthing Friendly” Feature on Care Compare
- Other Updates
- MedPAC Convenes for November Meeting
- MACPAC Convenes for November Meeting
- New York State Updates
- Governor Hochul Signs Legislation Addressing Infant and Maternal Mortality
- DOH Updates “In Lieu of” Services Guidance and Application
- DOH Releases Revised Proposed Regulations for Medical Respite Programs
- OPWDD Issues Updated Guidance to Reflect Expiration of Covid-19 Appendix K Waiver Flexibilities
- DOH Hosts Monthly Managed Care Policy and Planning Meeting
Administration Update
Senate Confirms Dr. Monica Bertagnolli for NIH
On November 7th, the Senate voted to confirm Dr. Monica Bertagnolli as the new director of the National Institutes of Health (NIH) by a vote of 62-36. Dr. Bertagnolli, a cancer surgeon by training, currently leads the National Cancer Institute. With her appointment, she will become only the second woman to lead the NIH on a permanent basis. Her confirmation was successful despite an objection by Senator Bernie Sanders (I-VT) related to prescription drug pricing policy concerns.
Federal Agencies
CMS Proposes MA Rule on Behavioral Health and Marketing
On November 6th, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule on contract year 2025 policy and technical changes for Medicare Advantage (MA) plans. Notable changes in the rule include:
- Behavioral health: CMS proposes to add a new specialty called “Outpatient Behavioral Health,” which will include practitioners like licensed mental health counselors (LMHCs) and licensed marriage and family therapists (LMFTs) and establish MA network adequacy standards for it.
- Broker compensation: CMS proposes to enact new guardrails on broker compensation to address the issue that larger plans are more likely to provide financial incentives to brokers. Specifically, the rule would establish a fixed maximum amount ($642) that brokers can be paid regardless of the plan in which the beneficiary enrolls. The rule also proposes to prohibit contractual arrangements between MA plans and “marketing middlemen” that include volume-based bonuses for enrollment.
- Supplemental benefits: CMS proposes to require MA plans to send notifications to enrollees on their unused supplemental benefits mid-year to encourage greater utilization.
The proposed rule is available here.
CMMI to Hold Office Hours for Making Care Primary on November 21st
On November 21st at 2pm ET, the Center for Medicare and Medicaid Innovation (CMMI) will hold office hours to answer questions related to the Making Care Primary (MCP) model. The office hours will be an interactive webinar, likely the last opportunity to ask questions in advance of the end of the MCP application period on November 30th. CMMI intends to launch the MCP model on July 1, 2024 in upstate New York and seven other states.
The registration is available here.
CMMI to Hold Listening Session to Hear Beneficiary Feedback on November 15th
On November 15th at 12pm ET, CMMI will hold a virtual Listening Session on beneficiary feedback. CMMI aims to better incorporate beneficiary feedback into model development, implementation, and evaluation.
Registration is available here.
CMS Launches “Birthing Friendly” Feature on Care Compare
On November 8th, CMS announced the launch of a new “Birthing Friendly” designation icon on its Care Compare online tool. This designation is meant to highlight hospitals and health systems that participate in a perinatal quality improvement program to improve maternal health. This creation meets a milestone of the CMS Maternity Care Action Plan.
The announcement is available here.
Other Updates
MedPAC Convenes for November Meeting
On November 2nd and 3rd, the Medicare Payment Advisory Commission (MedPAC) convened for its monthly public meeting. Among topics discussed, the Commissioners demonstrated an interest in stronger reporting around dual-eligible, special needs populations and establishing payment policies for software as a medical service. Commissioners were also interested in new analysis on network management and prior authorization in MA plans. The next MedPAC meeting will take place virtually on December 7th and 8th.
The slide decks from the meeting are available here.
MACPAC Convenes for November Meeting
On November 2nd and 3rd, the Medicaid and Children’s Health Insurance Program (CHIP) Payment Access Commission (MACPAC) met for its monthly public meeting. The Commissioners discussed and were supportive of policies surrounding the managed care appeals process but fell short of supporting required external medical review processes for beneficiaries in every state. Commissioners also weighed in on waivers states are using to prevent procedural terminations during the unwinding. Lastly, there was broad consensus that home and community-based services (HCBS) should be streamlined across states. The next MACPAC meeting will take place virtually on December 14th and 15th.
The slide deck from the meeting is available here.
New York State Updates
Governor Hochul Signs Legislation Addressing Infant and Maternal Mortality
On November 6th, Governor Hochul signed legislation (S1867A/A5435A) that requires the New York State (NYS) Department of Health (DOH) to create and maintain a New York directory of doulas. A doula is a trained birthing expert that provides physical, emotional, and informational support before, during, and after childbirth. The directory will support Medicaid reimbursement of doula services and will promote doula services to Medicaid recipients.
Doulas will not be charged a fee to be registered in the directory, but will be required to submit their certification from a doula educational organization or otherwise establish “satisfactory proficiency.” Doula coverage will be available to all Medicaid enrollees statewide starting January 1, 2024.
The Governor’s press release is available here.
DOH Updates “In Lieu of” Services Guidance and Application
On November 8th, DOH issued updates to the Medicaid In Lieu of Services or Settings (ILS) application process and guidance. In accordance with federal regulations, Medicaid Managed Care Plans (MMCPs) may offer enrollees cost-effective alternative services, known as “in lieu of services,” that are not included in the Medicaid State Plan. The updates include the following new (or not previously addressed) requirements:
- ILS must advance the objective of the Medicaid program, and therefore MMCPs must ensure that the alternative service or setting is approvable through a State Plan Amendment and does not violate any federal requirements;
- ILS must be medically appropriate, and MMCPs must use a consistent process for determination and documentation; and
- ILS must be provided in a manner that preserves enrollees’ rights and protection.
DOH also updated the application and approval process to indicate that all ILS must be reviewed and approved by CMS, in addition to DOH, prior to implementation. DOH expects this new requirement to significantly affect the approval process timeline.
The updated guidance is available here and an overview of the changes is available here. The updated application form is available here. Plans have until January 1, 2024 to conform with the guidance. Questions may be submitted to ILS@health.ny.gov.
DOH Releases Revised Proposed Regulations for Medical Respite Programs
On November 8th, DOH issued revised proposed regulations for not-for-profit entities seeking certification as Medical Respite Program (MRP) operators. The second Medicaid Redesign Team (MRT II) recommended, and the 2021-2022 Enacted NYS Budget authorized, the establishment of standards for medical respite programs as a lower-intensity care setting for patients who are homeless or at risk for homelessness and who would otherwise require a hospital stay or lack a safe option for discharge and recovery. Programs provide temporary room and board, allowing individuals to rest in a safe environment while accessing on-site medical care, care coordination, and other supportive services.
The rule would require that medical respite programs meet the minimum operating standards, offer the required services, provide sufficient qualified staff, implement a quality improvement program that is reviewed at least annually, meet the required physical standards of the facility, and maintain accurate and current records for each recipient. Following a public comment period on the proposed regulations (initially issued in October 2022), the State made several revisions, including but not limited to:
- Clarifying the certification, inspection, and surveillance process, including adding a requirement for programs to recertify every five years;
- Removing the requirement for respite programs to have at least one clinician available 24/7, instead only requiring at least one manager to be available onsite or by telephone 24/7 and “a sufficient number of staff members” available onsite 24/7 (DOH will issue additional guidance on staffing);
- Updating physical standard requirements;
- Adding clarifications to eligibility/admission requirements and the discharge process, including clarifying that recipients may be discharged without a permanent housing placement; and
- Requiring a recipient reassessment at least every two weeks to ensure that the recipient’s needs are addressed by the service plan.
The revised regulations are available here. Public comment may be submitted to regsqna@health.ny.gov through December 26th. There will be additional sub-regulatory guidance issued on eligibility, discharge, billing, record maintenance/retention, facility standards, length of stay, and personnel requirements.
OPWDD Issues Updated Guidance to Reflect Expiration of Covid-19 Appendix K Waiver Flexibilities
On November 11th, the NYS Office for People with Developmental Disabilities (OPWDD) Emergency Appendix K Waiver will expire. The Appendix K Waiver provided several flexibilities to support providers and ensure continuity of care during the Covid-19 pandemic. Some of these provisions have been made permanent, and some will expire with the waiver on November 11th. As a result, OPWDD has issued the following guidance to address changes in service provision associated with the end of the Appendix K authority:
- Requirements for Community Habilitation-Residential (CH-R) Services Delivered in the Individual’s Certified Residence (here)
- Ability to Use Technology to Remotely Deliver HCBS (here)
- Service Documentation for Community Habilitation Services (here)
- Group Day Habilitation Service Documentation Requirements (here)
A brief summary of the changes addressed in each guidance document is available here. While the updated guidance is effective November 11th, there will be a public comment period through December 8th. OPWDD may update and reissue the guidance based on comments received. Comments may be submitted to regulatory.affairs.unit@opwdd.ny.gov. OPWDD hosted a webinar to address the updates, a recording of which will be posted online here.
DOH Hosts Monthly Managed Care Policy and Planning Meeting
On November 9th, DOH hosted its monthly Managed Care Policy and Planning Meeting, which included an update on Medicaid enrollment reconciliation, the Managed Long Term Care (MLTC) program, recent changes to rates for behavioral health programs, and member and provider enrollment statistics. The webinar also provided updates on the carve-out of Non-Emergency Medical Transportation (NEMT) services, and indicated that DOH will begin carving out NEMT services from the MLTC benefit package in 2024 (exact date to be determined). DOH and the contracted NEMT broker, Medical Answering Services (MAS), will soon begin scheduling stakeholder meetings with MLTC plans to discuss the transition.
The webinar additionally included an update on the new five-year Medicaid Managed Care (MMC)/HIV Special Needs Plan (SNP)/Health and Recovery Plan (HARP) model contract, which will start on March 1, 2024 and end on February 28, 2029. The new contract will be identical to the contract under which plans are currently operating. Planned edits will be made as a first amendment to the 2024-2029 MMC/HIV SNP/HARP model contract.
The presentation is available here and the enrollment reconciliation update is available here. The NEMT update is available here and the behavioral health update is available here.